RESEARCH ARTICLE

eHealth for people with multimorbidity:

Results from the ICARE4EU project and

insights from the “10 e’s” by Gunther

Eysenbach

Maria Gabriella MelchiorreID*, Giovanni Lamura, Francesco Barbabella, on behalf of

ICARE4EU Consortium¶

Centre for Socio-Economic Research on Ageing, National Institute of Health and Science on Ageing, IRCCS

INRCA, Ancona, Italy

¶ Membership of the ICARE4EU Consortium is provided in the Acknowledgments

* g.melchiorre@inrca.it

Abstract

Background

People with multimorbidity, especially older people, have complex health and social needs,

and require an integrated care approach. In this respect, eHealth could be of support. This

paper aims to describe the implementation of eHealth technologies in integrated care pro-

grams for people with multimorbidity in Europe, and to analyse related benefits and barriers

according to outcomes from ICARE4EU study and within the more general conceptual

framework of the “10 e’s” in eHealth by Gunther Eysenbach.

Methods

In 2014, ICARE4EU project identified 101 integrated care programs in 24 European coun-

tries. Expert organizations and managers of the programs completed an on-line question-

naire addressing several aspects including the adoption of eHealth. Findings from this

questionnaire were analyzed, by linking in particular benefits and barriers of eHealth with

the “10 e’s” by Eysenbach (Efficiency, Enhancing, Evidence-based, Empowerment, Encour-

agement, Education, Enabling, Extending, Ethics, and Equity).

Results

Out of 101 programs, 85 adopted eHealth tools, of which 42 focused explicitly on older peo-

ple. eHealth could improve care integration/management, quality of care/life and cost-effi-

ciency, whereas inadequate funding represents a major barrier. The “10 e’s” by Eysenbach

seem to show contact points with ICARE4EU findings, in particular when referring to positive

aspects of eHealth such as Efficiency and Enhancing quality of care/life, although Empower-

ment/Education of patients, care Equity and Ethics issues seem crucial in this respect.

Encouragement of a new relationship patient-health professional, and Enabling

PLOS ONE | https://doi.org/10.1371/journal.pone.0207292 November 14, 2018 1 / 26

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OPEN ACCESS

Citation: Melchiorre MG, Lamura G, Barbabella F,

on behalf of ICARE4EU Consortium (2018) eHealth

for people with multimorbidity: Results from the

ICARE4EU project and insights from the “10 e’s”

by Gunther Eysenbach. PLoS ONE 13(11):

e0207292. https://doi.org/10.1371/journal.

pone.0207292

Editor: Katie MacLure, Robert Gordon University,

UNITED KINGDOM

Received: May 24, 2018

Accepted: October 29, 2018

Published: November 14, 2018

Copyright: © 2018 Melchiorre et al. This is an open

access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the manuscript and its Supporting

Information files.

Funding: This publication arises from the project

Innovating care for people with multiple chronic

conditions in Europe (ICARE4EU) Project, which

has received funding from the European Union, in

the framework of the Health Programme 2008-

2013 of the European Union, (CHAFEA, The

Consumers, Health, Agriculture and Food Executive

standardized exchange of electronic information, represent further aspects impacting inte-

gration/management of care.

Conclusions

Aspects of eHealth, which emerged as benefits and barriers impacting integration/manage-

ment of care, as well as cost-efficiency and quality of care/life, can be identified on the basis

of both ICARE4EU findings and the “10 e’s” in eHealth by Eysenbach. They could represent

objectives of new policies for supporting the deployment of eHealth technologies within inte-

grated care across Europe.

Introduction

An increasing number of people in Europe (about 50 million) is suffering from multiple

chronic conditions (MCCs) or multimorbidity, in particular 60% of those aged 65 years and

over [1]. On one side, multimorbidity implies several and complex health and social needs,

high healthcare utilization and the necessity of tailored integrated and patient-centered

approaches, On the other side, European health systems are not yet equipped to address the

comprehensive care needs of people with multimorbidity [2].

Needs of people with multimorbidity could be met by care services based on innovative

technologies, e.g. eHealth tools to support patients’ self-management and multidisciplinary

collaboration between professionals [3, 4]. eHealth is the use of Information and Communica-

tion Technologies (ICTs) in the healthcare sector. It is defined by the European Commission

as “the use of ICTs in health products, services and processes combined with organizational

change in healthcare systems and new skills, in order to improve health of citizens, efficiency

and productivity in healthcare delivery, and the economic and social value of health” [5].

eHealth tools can play a key role for a better integration of healthcare and social needs.

According to the seminal work by Eysenbach [6], eHealth is characterized by being more than

a “mere technological development”, that is “a state of mind, a way of thinking, an attitude and

commitment for networked, global thinking, to improve healthcare locally, regionally, and

worldwide by using information and communication technology”.

Some authors [7] wondered whether consensus had been reached on the definition of

eHealth or whether there is a need for a more comprehensive and in-depth review of the litera-

ture. In particular, a qualitative study by Pagliari and colleagues [8] found 36 different defini-

tions of eHealth. The original definition by Eysenbach was confirmed, but it was integrated, by

adding that eHealth allows a new way of providing traditional healthcare [9].

More recent terms refer to eHealth as “connected health”, that is the integration of technol-

ogy into healthcare [10], or as “ubiquitous health”, that is the dynamic network of interconnec-

ted systems [11]. Furthermore, the expression “intelligent health” is sometimes used to

indicate the transformation/analysis of electronic data, obtained by means of eHealth tools,

into knowledge and the consequent integration of real-time self-monitoring with assessment

of patient’s environment, including also information from family caregivers [12].

The question is that eHealth is a comprehensive and wide concept, an “umbrella” term

including various domains, services and applications of ICT on prevention, care, rehabilitation

and support, also enabling and interconnecting health service processes and actors, in place

and remotely [13]. In order to understand the role of eHealth tools for addressing needs of

people with multimorbidity, it seems necessary to group, first of all, eHealth tools within a

eHealth for people with multimorbidity

PLOS ONE | https://doi.org/10.1371/journal.pone.0207292 November 14, 2018 2 / 26

Agency, http://ec.europa.eu/chafea/), Grant number

20121205. Duration of the project: 2013-2016.

This study was partially supported by Ricerca

Corrente funding from Italian Ministry of Health to

IRCCS INRCA. The funders had no role in study

design, data collection and analysis, decision to

publish, or preparation of the manuscript.

Competing interests: The authors have declared

that no competing interests exist.

dedicated framework. According with the classification from the Chronic Care Model (CCM)

[14, 15], the key elements of health system/disease management are the following: self-man-

agement support, delivery system design, decision support, clinical information systems, and

community resources and policies. When the CCM is implemented with the integration of

eHealth tools, that can be used to improve the management of chronic illnesses, the model can

be re-framed as suggested by the eHealth Enhanced Chronic Care Model (eCCM) [16]. The

eCCM in particular showed that eHealth tools can provide important contributions to chronic

care, due to their potential impact on: self-management support, e.g. electronic reminders,

mobile applications; delivery system design, e.g. tools for supporting care coordination; deci-

sion support, e.g. online protocols/guidelines; clinical information systems, e.g. Electronic

Health Records (EHRs) including health data of patients regarding prescriptions, medications,

vital signs, and laboratory diagnostic examinations. In addition, eHealth education, by means

of ICT tools, can provide users with electronic skills when needed, as crucial aspect of self-

care.

European countries have implemented some eHealth tools in their healthcare systems, but

in most cases they are not integrated in care practices and routines supporting patients with

MCCs. In particular, concerning the deployment of eHealth in Europe, Nordic European

countries seem to be the leaders in the implementation of eHealth tools, whereas Eastern and

Southern Europe include the lesser performing nations, with some exceptions like Spain [13,

17]. A recent World Health Organization (WHO) survey on eHealth [18] showed in particular

that 70% of European countries have a national eHealth policy or strategy and 80% have a

national legislation to protect the privacy of EHRs, but only 59% have a national EHR system

and 69% of these have a legislation concerning its use.

With regard to benefits of using eHealth, previous studies [19–21] showed improved coor-

dination and continuity of care (crucial for older people) by enhanced opportunities for digital

data sharing, communication and consultation at distance. Furthermore, valuable reductions

in overall hospital admissions, length of stay, and healthcare utilization costs are reported [22].

In particular, the use of eHealth technologies in home care for older people can be cost-effec-

tive, even if only family caregivers benefit from it [23]. Patients have the chance to overcome

logistic and cost barriers for accessing healthcare services, especially when living in remote and

rural communities [24]. Patients can furthermore benefit from improved self-care/manage-

ment, independent living at home and patient empowerment (especially for the older people),

better monitoring and continuity of care, adherence to treatments and maintaining or improv-

ing their health status. All this leads to better outcomes for patients [22] and family caregivers

[21].

However, there are still various barriers limiting the adoption of eHealth technologies [25–

28]. These barriers can be [13]: regulative (e.g. lack of a clear/dedicated legislative framework);

technical (e.g. low overall standardization and compatibility/interoperability between different

tools, and inadequate technical support and infrastructures); economic (e.g. lack of financing

and adequate funding, lack of reimbursement and incentives systems, limited large scale evi-

dence addressing cost-effectiveness of eHealth solutions); and cultural-social (e.g. possible cul-

tural resistance to technology both by professionals and patients, scarce perception of and

willingness to use eHealth, and low/lacking integration of the end-users into the development

process, particularly for the older people). The lack of adequate eHealth processes also hinders

the integration within existing healthcare systems [29, 30].

Benefits and barriers of eHealth are in particular crucial aspects concerning its implementa-

tion and adoption process, and Eysenbach in this respect proposed a conceptual framework

for framing the potential impact and key factors of eHealth. In his seminal work [6], “10 e’s” in

eHealth were listed and described: Efficiency, Enhancing, Evidence-based, Empowerment,

eHealth for people with multimorbidity

PLOS ONE | https://doi.org/10.1371/journal.pone.0207292 November 14, 2018 3 / 26

Encouragement, Education, Enabling, Extending, Ethics, and Equity. As stated by Eysenbach

himself, “the ‘e’ in eHealth does not only stand for ‘electronic’ but implies a number of other

‘e’s’ which together perhaps best characterize what eHealth is all about or what it should be”.

In the light of these considerations, the aim of this paper is to describe the implementation

of eHealth technologies in integrated care programs for multimorbidity in Europe and to ana-

lyse in particular their benefits and barriers, within the more general conceptual framework of

the “10 e’s” by Eysenbach. The hypothesis is that, although these were not specifically formu-

lated for eHealth in relation to multimorbidity care and were proposed more than 15 years

ago, they may be still valid and have many contact points with ICARE4EU findings, with valu-

able implications regarding particularly benefits and barriers of eHealth for people with

MCCs.

Materials and methods

Data sources/Collection

The integrated care programs that are analyzed in this paper come from the European project

“Innovating Care for People with Multiple Chronic Conditions in Europe” (ICARE4EU). This

project (2013–2016), co-funded by the European Union (EU), mapped innovative care

approaches for people with MCCs, which have been developed and implemented in 31 Euro-

pean countries.

Programs were considered for inclusion in the survey when meeting all the following crite-

ria: they targeted adult people (aged 18 and older) with multimorbidity, defined as two or

more medically diagnosed chronic or long lasting diseases; they included formalized collabora-

tion(s) between at least two services; they involved one or more medical service(s); they were

evaluable or evaluated; they were either still ongoing (in 2014), just finished (less than 24

months before) or about to start (within the following 12 months).

Information on programs was collected with the support of organization experts and pro-

gram managers in each country included in the study. The experts and managers had expertise

on multimorbidity care and were in turn supported by their own extensive network/staff and

program leaders. They were asked to identify existing (national, regional and/or local) inte-

grated care programs focusing on multimorbidity in their country, and to report related

detailed information by means of a link to a web-survey, and filling in an online questionnaire

for each eligible program. The online questionnaire was developed in English and made avail-

able in eleven languages. It contained general questions, e.g.: target group/sub-groups of

patients, i.e. older people aged 65+, people with physical/cognitive impairments, informal

caregivers; specific gender/age as inclusion criteria of the program; particular health problems

(e.g. sensory/psychological), as exclusion criteria of the program; main diseases addressed by

the program; main objectives, implementation level, types of organizations involved; quality

and evaluation of the program. In addition, key elements of multimorbidity care were

addressed from the following perspectives: patient-centeredness, e.g. capacity to tailor care

according to the specific patient’s needs; management practices and professional competen-

cies, e.g. organizational aspects of providing integrated care; financing mechanisms, e,g, source

of funding, savings, incentives; and use of eHealth technologies, e,g, if and how ICT tools were

implemented for supporting multimorbidity care. The country experts identified 101 pro-

grams, from 24 European countries, responding to the inclusion criteria.

Furthermore, eight good practices (high potential programs) were selected for an in-depth

case study analysis, including site visits and further qualitative data collection. To this end, the

project team assessed all 101 programs on the basis of a mix of quantitative and qualitative cri-

teria, regarding general dimensions (e.g. evaluation design, perceived sustainability and

eHealth for people with multimorbidity

PLOS ONE | https://doi.org/10.1371/journal.pone.0207292 November 14, 2018 4 / 26

transferability) and more specific aspects (e.g. level of patient-centeredness, integration of

care, use of eHealth technologies and innovativeness in financing mechanisms). This led to

identify the ‘top’ eight ‘high potential’ programs, and further information on their contexts

and ordinary activities were gathered by means of case studies. The team used a common topic

guide-questionnaire for conducting face-to-face and semi-structured in depth interviews with

experts/managers and program staff (approximately five interviews per program) in dedicated

site visits. Information collected was integrated by additional documents (e.g. internal reports,

evaluations) for developing case study reports.

More detailed descriptions of selection of initiative which were visited, in addition to inclusion

criteria and data collections, are reported elsewhere [31–33]. For this paper, only information from

the quantitative survey was analysed, without including information from the eight good practices.

Ethics statement

For the ICARE4EU project, no ethical approval was requested, given that the study aimed at collect-

ing secondary data already available to country experts/managers and staff of integrated care pro-

grams for people with multimorbidity, without collecting personal/clinical data on sensitive

questions regarding patients and family carers. The project team used a web-survey with restricted

access (by setting individual access credentials) which was filled in by leading organizations, in addi-

tion to some interviews during the site visits to eight ‘high potential’ programs, as explained above.

Only general data on the programs was collected. Patients and their family caregivers were not

approached. Consequently there were no issues concerning their privacy and anonymity. A written

agreement/consent was signed by experts/managers and program staff to contribute to the study

and regarding the confidentiality of data collection on care programs selected in their countries.

Measures

ICARE4EU study distinguished four categories of eHealth tools by their main functions [31,

34] and adopted its own classification by adapting elements of the conceptual frameworks

from CCM and eCCM [16]. The four types of eHealth are ICT tools for:

• Remote Consultation, Monitoring and Care: providing remote interaction between patients

and health professionals at distance, e.g. consultations/visits by telehealth/telecare,

ePrescriptions;

• Self-Management: promoting ability to self-care, used by patients to live more indepen-

dently, e.g. wearable devices/assistive technologies providing health advice and reminders;

• Healthcare Management: for improving the integration/communication, quality and effi-

ciency of care processes within and between care providers, e.g. EHRs, e-referral systems;

• Health Data Analytics: for analysing data in patient databases and/or clinical evidence for

prevention, monitoring and treatment purposes, e.g. Decision Support Systems (DSSs) used

by health professionals for clinical decision-making.

Further aspects that were analyzed in the ICARE4EU study were training on use of eHealth,

data privacy/security provision, and innovation of the program (as capacity to develop new

eHealth tools). Moreover, opinions on potential benefits (improving quality of care, quality of

life of patients enrolled, integration/management of care, cost-efficiency) and barriers (inade-

quate legislative framework, funding, ICT infrastructures, technical-ICT support; lack of skills

and cultural resistance among care providers and patients; uncertainty about cost-efficiency;

compatibility/interoperability between different eHealth tools; privacy/security issues), were

addressed as perceived by experts and program managers. Finally, the provision of incentives

eHealth for people with multimorbidity

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for both providers (e.g. for additional staff) and patients (e.g. reimbursement, free access to

devices/services), and aspects of evaluation/monitoring of the program, were included. These

last two dimensions (incentives, evaluation) in our study were not assessed specifically/only

for programs with eHealth adoption (as the other measures mentioned above), but with regard

to all the mapped integrated care programs. These were then analyzed only with regard to pro-

grams using at least one eHealth tool for the purpose of this paper. More detailed description

of measures is reported in a separate paper [31].

The “10 e’s” in eHealth by Gunther Eysenbach [6], that were used as conceptual framework

to compare ICARE4EU findings, are those already mentioned in the “Introduction” of this

paper. They are described with more detail below:

1. Efficiency: to increase efficiency in healthcare by decreasing costs;

2. Enhancing: the quality of care;

3. Evidence based: of eHealth interventions;

4. Empowerment: of consumers and patients;

5. Encouragement: of a new relationship between patient and health professional;

6. Education: of physicians and consumers;

7. Enabling: standardized information exchange and communication between providers;

8. Extending: the scope of healthcare in a geographical and conceptual sense;

9. Ethics: ethical issues, informed consent, privacy;

10. Equity: to make healthcare more equitable among the population.

Data analysis

A quantitative data analysis was performed including the 101 integrated care programs target-

ing people with multimorbidity on their use of eHealth solutions (e.g. frequencies and bivari-

ate relations). Then the (reported) benefits and barriers of the identified eHealth programs

were analysed for further insights. The statistical software SPSS 23.0 was used to carry out the

quantitative analyses.

A qualitative data analysis was performed by further exploring findings on programs with

eHealth adoption, mainly in terms of benefits and barriers, as well as of EHRs use and access,

evaluation of programs, training of patients and providers, incentive mechanisms, and innova-

tion. In this respect, a manual coding process was provided [35]. It led to inductive content

analysis [36] of main themes, concepts and relations emerging from the ICARE4EU findings,

with the purpose of identifying links with the “10 e’s” conceptual framework by Gunther

Eysenbach [6]. The aim was therefore to bridge the above mentioned key aspects of eHealth

implementation process, as these come from the ICARE4EU findings, with the classification

by Eysenbach, and to understand whether these “e’s” were associated to one or more benefits

and barriers (and other relevant findings) from our study.

Results

Outcomes on eHealth

The findings in this paragraph partly represent a synthesis from a previous publication of the

authors, where more detailed description of results is reported [31]. Relevant (and further)

eHealth for people with multimorbidity

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data underlying the findings (S1 and S4 Tables), as well as the survey questions used in this

study (S1 Text) and the minimal anonymized dataset used for the analyses (S1 Dataset), can be

found as Supporting Information in this paper.

Among the 101 integrated care programs mapped on the whole by the ICARE4EU study,

85 included the use at least of one eHealth tool. Out of these 85 programs, 42 focused explicitly

on older people aged 65 years and over. The highest number of programs with eHealth tools

were identified in Spain (15), followed by Greece, Iceland and Germany (7 in each country),

Italy (6) and Finland (5). In the 18 remaining countries, only 1 (e.g. Portugal, Slovenia and Lat-

via) to 4 programs (e.g. Netherlands, Denmark and Sweden) used at least one eHealth tool.

The main reported aim of these programs was to increase multidisciplinary collaboration

(85%), whereas organizations and care providers most involved were primary care providers

(71%) and General Practitioners (GPs, 80%). The implementation of the initiatives was mostly

local and/or regional (78%) and 45% of programs was fully integrated into the regular health-

care services (S1 Table).

Among the eHealth tools which were used, it was reported mostly EHRs (71%), followed by

registration databases with patients’ health data for supporting decision-making (64%) and

digital communication between care providers (47%). Further eHealth applications (e.g. elec-

tronic reminders, computerized DSSs for professionals, and health monitoring and interaction

at distance) were not yet widely implemented (S2 Table).

Access to EHRs was mainly allowed to medical care providers involved in care delivery

(58%) and less to patients themselves (10%). Moreover, 52% of these programs provided train-

ing on the use of eHealth tools to the care providers, but only 24% provided it to the patients

and/or family caregivers. About 70% of the surveyed programs assured privacy and confidenti-

ality of health data, and 59% provided data security. Furthermore, the scarce provision of

incentives for both providers (28 programs) and patients (only 18 programs) emerged. Con-

cerning the further key issue of evaluation, the results showed that this activity was mainly con-

ducted internally (70%) and less externally (33%). Furthermore, evaluation regarded most the

process (69%) and less the outcomes (43%) and cost-effectiveness (30%). Concerning innova-

tion, only 35% of programs specifically developed eHealth tools (24% used existing tools and

15% adapted them) (S3 Table).

The most frequently reported benefits of using eHealth, as perceived by the program man-

agers (Table 1), were on the whole improvements in the management and integration of care

(respectively 95% and 93% of program managers agreed) and in the quality of care provided

(86%). Other benefits were reported in terms of cost-efficiency of the program (76%) and in

the quality of life of patients enrolled (70%). All these benefits were moreover more evident

with regard to the integrated programs targeting the older people (Table A in S4 Table)

Table 1. Benefits of using eHealth tools included in the programs from the ICARE4EU study (% of agree)a.

Benefits Programs with at least 1 eHealth tool, N = 59

N %

Management of care 56 95

Integration of care 55 93

Quality of care 51 86

Cost-efficiency 45 76

Quality of life 41 70

a Multiple answers were allowed.

https://doi.org/10.1371/journal.pone.0207292.t001

eHealth for people with multimorbidity

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Inadequate funding (60%) emerged as the main barrier hampering the use of eHealth tools

in integrated care programs (Table 2). Inadequate interoperability and technical infrastructure,

lack of skills among patients/providers, and lack of a legislative framework also emerged (45–

50%). In addition, uncertainty on cost-efficiency of the program, privacy and security issues,

resistance to adopt eHealth tools by providers (33%) and patients (22%) were mentioned with

a lower rate of agree (22–40%). Regarding barriers, large differences between programs target-

ing adults or older people were not found (Table B in S4 Table). In particular, the lack of skills

among patients seems at the same level in programs for both groups.

Outcomes on eHealth and the “10 e’s” by Eysenbach

An analytic framework (Table 3) was developed in order to link our findings to the conceptual

scheme of the “10 e’s” in eHealth by Gunther Eysenbach [6]. Benefits and barriers were mainly

considered, in addition to other selected results (last column of Table 3, e.g. EHRs use and

access, evaluation of programs, training of patients/providers, incentives mechanism and

innovation) which were considered useful, as further potential barriers or consequences of

other barriers, to reinforce our considerations.

ICARE4EU findings, in particular on benefits and barriers, were analysed without their

respective percentages and without listing them in order of importance as perceived/referred

by the program managers. Conversely, all of them were explored as crucial aspects of eHealth

adoption, to better compare our results with the specific “10 e’s” by Eysenbach. In particular,

in many cases more results could be associated to these essential “e’s”.

Both Eysenbach and ICARE4EU study put in evidence (cost-) Efficiency and Enhancingquality of care and life. These aspects represent potential benefits of eHealth which could be

hampered by inadequate funding and incentives, and by the lack of appropriate program eval-

uations, which conversely could provide useful Evidence based data on efficiency itself. Lack of

adequate financing mechanism and uncertainty about cost-efficiency in turn could affect the

possibility of innovation, that is developing new ad hoc eHealth tools.

Furthermore, Empowerment of patients, Ethics issues, Education of patients/health profes-

sionals, and care Equity, are further aspects of eHealth related to quality of care/life. In this

respect, other aspects could represent crucial obstacles for the adoption of eHealth solutions,

Table 2. Barriers for using eHealth tools included in the programs from the ICARE4EU study (% of agree) a.

Barriers Programs with at least 1 eHealth tool, N = 58

N %

Inadequate funding 35 60

Compatibility between different eHealth tools 32 55

Inadequate technical ICT support 32 55

Inadequate ICT infrastructures 31 53

Lack of skills among patients 30 52

Inadequate legislative framework 29 50

Lack of skills among providers 26 45

Uncertainty of cost-efficiency 23 40

Privacy/security issues 20 35

Resistance by care providers 19 33

Cultural resistance 15 26

Resistance by patients 13 22

a Multiple answers were allowed.

https://doi.org/10.1371/journal.pone.0207292.t002

eHealth for people with multimorbidity

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such as lack of skills of patients and providers, their cultural resistance “to change”, inadequate

legislative framework and funding, and privacy/security issues, in addition to few training

opportunities for patients. Limited funding can further negatively impact investment in educa-

tion and training services for both users and providers. This negative context then could in

turn impact empowerment and lead to low access to EHRs by patients themselves.

Finally, other aspects represent conditions that could positively impact and improve both

integration and management of care due to eHealth adoption, like: Encouragement of a new

relationship between patient and health professional, Enabling standardized information

exchange between providers, and Extending the scope of healthcare in a geographical and con-

ceptual sense. Also these potential benefits can find obstacles, such as general cultural resis-

tance to adopt eHealth, inadequate funding and incentives, lack of technical infrastructure and

support, problems of compatibility and interoperability between different tools, and privacy/

security issues. These aspects moreover could affect the possibility to “encourage” access to

EHRs by patients, and the possibility of innovation with eHealth tools.

Discussion

Drawing on evidence from our ICARE4EU study, the use of eHealth tools, as referred by coun-

try experts and program managers, seemed to show some potential benefits, mainly as support

for management/integration of care, as well cost-efficiency and quality of care and life. On the

other side, findings suggested some issues and challenges, which could represent strong

Table 3. Benefits and barriers of/for using eHealth tools: ICARE4EU findings and framework by Eysenbach.

“10 e’s” in eHealth by eHealth Benefits from eHealth Barriers from Further findings from

Gunther Eysenbach ICARE4EU study ICARE4EU study ICARE4EU study

Efficiency Cost-efficiency Inadequate funding Scarce provision of incentives

Enhancing quality Quality of care Uncertainty about cost- Low both internal/external

Evidence based Quality of life efficiency evaluation

Low innovation (eHealth tool

developed ad hoc for the

program)

Empowerment Quality of care Lack of skill of patients Mainly training to care providers

Ethics Quality of life and care providers and less to patients

Education Resistance by patients Low access to EHRs by patients

Equity and care providers

Cultural resistance

Inadequate funding

Inadequate legislative

framework

Privacy/security issues

Encouragement Integration of care Resistance by patients Low access to EHRs by patients

Enabling Management of care and care providers Scarce provision of incentives

Extending Cultural resistance Low innovation (eHealth tool

Inadequate funding developed ad hoc for the

Compatibility between different program)

eHealth tools

Inadequate technical support

Inadequate ICT infrastructures

Privacy/security issues

https://doi.org/10.1371/journal.pone.0207292.t003

eHealth for people with multimorbidity

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barriers (infrastructural, technical, economic, legislative and practical) to the wider deploy-

ment of eHealth, with a consequent negative impact on the quality of care and quality of life of

patients. In particular, benefits were more evident with regard to programs focusing older peo-

ple, whereas barriers did not show substantial differences between programs targeting adults

or older people.

Overall, these interrelated issues were highlighted (in similar terms) also by Eysenbach,

although his work was not exclusively focused on eHealth solutions targeting people with mul-

timorbidity. In this respect, some further considerations and reflections can be highlighted on

the basis of both ICARE4EU findings and the “10 e’s” by Eysenbach [6], with large support

from existing literature, in order to identify ways of “bringing about change” in the general

implementation process of eHealth [37].

Efficiency, Enhancing quality of care, Evidence based initiatives

Efficiency, Enhancing quality of care, and Evidence based programs represent aspects of

eHealth which are strictly related each other, given that increasing efficiency could involve

both reducing costs and improving quality of care and life, in particular for the older people,

(as emerged from ICARE4EU data), but in the same time eHealth interventions should be evi-

dence-based, that is with expected effectiveness and efficiency supported by scientific data and

facts produced by rigorous evaluations.

Increasing Efficiency in healthcare is one potential key”promise” of eHealth, and cost-sav-

ings could result from avoided hospitalizations, or “duplicative/unnecessary diagnostic/thera-

peutic interventions, through enhanced communication possibilities between health care

establishments, and through patient involvement” [6]. de Bruin and colleagues [38] also

focused on improvements to existing integrated care initiatives (in particular for older people

with multiple health and social care needs), especially in relation to efficiency, defined as effec-

tive use of infrastructure, resources, equipment and technology for sustainability and reduc-

tion in healthcare spending. Such a positive economic impact of eHealth, as reduction in

hospital days per patient and overall cost-savings (as direct consequence of better clinical out-

comes and well-being of the patients), is supported for instance by results of introducing home

telemonitoring in various countries (e.g. Netherlands, UK and Germany). Furthermore, sav-

ings from adoption of digital prescriptions are reported [39]. In particular, the increased

multi-professional collaboration, thanks to innovative technologies, can lead to savings [40].

These circumstances can have positive consequences for Enhancing quality of care and life

[41], by “allowing comparisons between different providers”, in order to choose the best opportu-

nities in terms of quality [6]. European Commission [42] stressed the importance to direct

national eHealth governance towards delivery of citizen-centric healthcare, with patients actively

involved for the maintenance of their own health. With particular regard to older persons, this

new vision of care produces social returns, as their improved independence at home (e.g. by

reducing falls, preventing and combating depression and isolation, and developing informal net-

works), in addition to improved quality of life of their family caregivers [43]. In this respect, a new

frontier is represented by eHealth platform for older people and their caregivers, providing infor-

mation and support to facilitate and optimize caregivers’ work and to improve elders’ quality of

life [44, 45]. Recent findings confirmed that the use of the network consulting room (e.g. mobile

platform, with patient interacting through video, voice and text with the doctors) can improve the

quality of life of patients and reduce the number of re-hospitalization [46]. A recent literature

review suggested that web-based interventions, for supporting informal caregivers of adult people

with chronic conditions living in the community, can improve general health outcomes of care-

givers themselves (e.g. reduced depressive and anxiety symptoms) [47, 48].

eHealth for people with multimorbidity

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The possibility to have economic support for clinicians seems to play a role when adopting

technological innovations [49]. In general, the lack of adequate financing sources, as well as

limited incentives and reimbursement mechanisms (as emerged from ICARE4EU results),

have a negative impact on a widespread utilization of eHealth applications, and in particular of

telehealth services [50]. As with other technological innovations, some clinicians will adopt

them readily, whereas others will need incentives and support. Conversely, it seems strategic to

develop innovative and sustainable financing and reimbursement mechanisms for eHealth,

and to assess how financial flows in healthcare and welfare systems may provide incentives for

telehealth provision [25, 51]. Incentives should regard patients and health workforce, and

should involve industry and other relevant stakeholders for a full success in eHealth adoption

[52]. Furthermore, in the light of a multidimensional approach, adequate financial schemes

should try to overcome the separation of budget for health and social care services, currently

existing in many European countries [26]. In this respect, the use of “joint budgets” across

health and social care sectors could represents a good policy option to support the use of

eHealth and to promote continuity of care for people with MCCs [53]. In particular, shared

“service centres” could be of help in facilitating the wider deployment of telemedicine [54].

The fact that, according with ICARE4EU findings, inadequate funding represents a major

barrier hindering the adoption of health technologies, suggests that the financial context in

some countries (for instance in Eastern European countries) may affect the development of

reforms directed at the care for people with multimorbidity [55], including the exploitation of

eHealth potential. Moreover, the scarce provision of incentives for both providers (e.g. for

additional staff) and patients (e.g. increased reimbursement, free access to devices/services),

makes difficult a wider adoption of integrated programs using eHealth tools, especially in the

light of the financial constrains in public healthcare budgets for most European countries [56].

In particular, recent findings highlighted that, although policies on remote monitoring existed

in some European countries together with pilot projects, the need for capital investment was

not satisfied and formal incentives were scarce [57].

Another aspect impacting Efficiency and Enhancing quality of care and life is the lack of sys-

tematic evaluations of programs adopting eHealth, either conducted internally or externally.

When available, evaluation seems mainly internal in most cases, according to ICARE4EU find-

ings. Evaluation could provide useful Evidence based data on cost-efficiency itself. eHealth

interventions should be evidence-based, and effectiveness and efficiency “should not be

assumed” but supported by rigorous scientific evaluation [6]. Currently, there is a lack in the

number of large rigorous clinical trials and field research studies, which could provide evi-

dence on health outcomes and other effects [41, 50, 58]. Conversely, it seems crucial to con-

duct, synthesise and use evidence from large-scale studies on (cost-) effectiveness of eHealth

applications (e.g. on satisfaction of service users and health/social care professionals, and

related costs) [26].

Large-scale interventions are especially needed to evaluate the impact of eHealth tools,

rather than small-scale research, since these latter ones cannot evaluate effectively the impact

itself [34]. “The impact of eHealth technologies is sometimes questioned because of a mis-

match between the postulated benefits and actual outcomes” [59]. Moreover, it should be

highlighted that changes involving eHealth adoption are challenges which require sufficient

financial resources and additional investments for a long period of time, in order to have

eHealth services actually “paying off” [26]. As a consequence of this, there is a need for long-

term studies to verify the sustainability of benefits eventually emerging from short-term trials

[60]. In order to have eHealth technologies confirming their durability and acceptance for

patients on the long-term [58], care programs with eHealth should be designed with “evalua-

tion in mind” and with considerations on possible integration within the healthcare system,

eHealth for people with multimorbidity

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especially in relation to benefits and effectiveness within routine settings [61]. In particular,

the economic impact of eHealth seems urgent to be evaluated with regard to older people with

MCCs, given that studies referred an exponential association between multimorbidity in later

life and healthcare costs [62], in order to adapt care programs at best to their specific needs

[63].

The lack of sufficient empirical evidence on costs and benefits, thus generating uncertainty

about cost-efficiency, make healthcare professionals often “skeptical” on the potential of

eHealth technologies. It seems important to monitor outcomes in order to better inform and

drive decisions of relevant stakeholders (e.g. on human resources and financing requirements).

Conversely, findings from the ICARE4EU study showed that evaluation of programs regarded

most the process and less the outcomes. Motivated stakeholders could be available to use e.g.

telehealth solutions, but evidence is needed in order to invest in digital health services [64].

Systematic evaluation of eHealth interventions and scientific evidence could convince policy-

makers, who often refer low access to good quality evidence, and the lack of timely research

output, as crucial barriers to the use of evidence [65]. A recent review [66] in particular

highlighted the importance to improve eHealth evaluations by measuring adherence of out-

comes to the “intended use” of different eHealth technologies.

The lack of adequate financing and incentives mechanisms in turn negatively impacts the

possibility to provide appropriate internal and external evaluations of the eHealth tools. This

may limit the possibility of innovation and the development of new eHealth tools, given that

investors need to have robust evidence on economic returns, in order to be willing to finance

new care programs with eHealth [59, 67]. In this regard, from ICARE4EU results emerged that

only few programs specifically developed new eHealth tools. These programs should show

their sustainability depending on their evidence based ability to generate social and economic

returns (e.g. by generating savings), with a business model that is affordable for the users [43].

Digital transformation is a great opportunity to increase health care performance “by lowering

cost and improving quality of care”, but in this respect, and regarding an economic scale,

“business models can be strengthened” [68].

Empowerment, Ethics, Education, Equity

Empowerment of patients, Ethics issues, Education of patients and health professionals, in addi-

tion to care Equity, are further aspects of eHealth impacting quality of care and quality of life,

thus enabling patient-centered care. In this respect, there are some obstacles preventing a fruit-

ful adoption of eHealth solutions, as emerged also from the ICARE4EU study, such as the lack

of guarantees of privacy and confidentiality of data, inadequate legislative framework, lack of

skills of patient/providers, their cultural resistance “to change”, and few training opportunities

for patients.

Empowerment of patients, in particular, implies to support self-management of people with

multimorbidity living at home, through tools providing feedback or check of adherence to

treatment, including tools that educate and empower them in self-care [34, 69]. eHealth is

indicated as a key driver for developing patients’ empowerment [27, 70]. Empowerment of

patients, and their involvement in decision making processes, can be reached, for instance, “by

making personal electronic records accessible to consumers over the Internet” [6]. The oppor-

tunity to access these records (EHRs in ICARE4EU study), makes individuals more active and

controllers and responsible of their own health data concerning disease, treatment and preven-

tion, with the right to make decisions on management of their wellbeing, and to be informed

about how their health data will be used. The possibility for patients to access them can

increase their trust in care providers, and this can allow easier communication with health

eHealth for people with multimorbidity

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professionals [71]. In this respect more than eight out of ten Europeans [72] indicate that they

do not feel that they have a complete control of their personal data online. ICARE4EU study

also highlighted that access to EHRs was allowed to patients only in few cases, and that in par-

ticular a lack of digital skills among patients and providers represented a barrier in about half

of the mapped care programs adopting eHealth tools for multimorbidity. In addition, the gen-

eral cultural resistance to understand and appreciate the usefulness of eHealth tools, and few

dedicated opportunities of education and training on eHealth, especially for patients, emerged

as aspects to be considered.

Empowerment of patients and online self-management involve in particular Ethics aspects

concerning privacy/security and informed consent by patients [6], and this in turn could

involve aspects related to training needs for patients on these issues. In particular training for

users of telecare is an important factor for improving patient safety [73]. These aspects should

be mandatory when adopting eHealth, within a clear and dedicated legislative framework. In

particular, potential opportunities and threats of eHealth should be identified before design-

ing/planning an ethical framework [74]. ICARE4EU findings indicated that not all the sur-

veyed programs assured privacy and security of personal medical data. Moreover, WHO [18]

highlighted that currently not all European countries have fully addressed this issue. As already

put in evidence, 80% have a national legislation protecting the privacy of EHRs, but only 59%

have somehow a national EHR system, and 69% have a legislation concerning its use. The lack

of legal and regulatory issues should be addressed, in addition to privacy and security issues,

especially when patients are moving from an institutional setting to their homes (protected

discharge) [26]. Moreover, the implementation of guidelines assuring a safe use of digital

health tools and data could be of great help [75].

Education of “consumers” and “of physicians through online sources (continuing medical

education)” [6], in addition to education of formal and informal caregivers, represent key

aspects impacting the Empowerment issue. eHealth enables efficiency, quality and continuity

of care but requires adequate education of all actors involved, on potential capabilities and

benefits coming from ICTs. Health professionals, in particular, could have great help from

online systems, e.g. eLearning platforms for vocational training [76]. However, first of all there

is a need of more digital skills training and support in order to have competencies in clinical

informatics for medical education [19, 77].

eLearning, in particular as computer-based educational intervention for GPs, seems effec-

tive in enhancing their competencies in communication with older patients [78]. With regard

to patients, it is important to enhance. “eHealth literacy” or ‘digital health literacy’ as a key

pre-condition for the acceptance of eHealth tools and their use for self-care and management

[16]. Having ‘digital health literacy’ means to have adequate skills in order to access, under-

stand, use and benefit from both electronic health information and tools [79]. More in general,

older patients have a low ‘health literacy’, intended as the capacity to comprehend basic health

information from healthcare providers or from traditional sources (e.g. instructions for medi-

cines), and it is more likely that they have also a low ‘digital health literacy’, with the conse-

quent need of particular assistance in using both traditional and ICT-based information, care

and self-management [29, 80]. In most cases, there is indeed a digital divide in older adults,

due to their decline in cognitive and physical functionalities related to the aging process, and

to their negative attitudes toward technologies [81, 82]. The digital divide between young and

older people is also put in evidence by Eysenbach [6]. ICARE4EU data report that the lack of

skills (for using eHealth tools) among patients seems at the same level with regard to care pro-

grams for both adult people in general and older people in specific. Moreover, when imple-

menting new eHealth applications, professional care staff can play a key role, but professionals

should themselves first of all believe in the potential benefits of new technologies for the

eHealth for people with multimorbidity

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patients [83]. Nursing personnel represents in particular a large group of health care profes-

sionals from whom a successful implementation of eHealth applications depends. They could

be sustained by the support of adequate training enhancing the adoption of eHealth by patients

[70]. Nurse practitioners educated/empowered in/with telehealth could strongly support

health care, and related innovations, within practice [84].

Limited funding can further negatively impact investment in education and training ser-

vices, for both users and providers, on eHealth tools use. This negative context then could fur-

ther lead to unequal access to technology among people. Equity and social inclusion in eHealth

adoption represent thus other issues to be considered. “To make health care more equitable is

one of the promises of e-health”, but policy actions seem necessary to ensure “equitable access

for all” [6]. Health interventions delivered via internet or mobile phone apps, can provide

“promising alternative health-care delivery models”, especially for marginalized and excluded

populations [85]. Inequalities in eHealth adoption could lead, for instance, to low access to

EHRs by some group of more disadvantaged/vulnerable patients who are socially isolated, e.g.

without digital skills, with lower socioeconomic status, living in deprived and rural areas, with

lacking technological infrastructure, and with low mobility [86]. The digital divide is not the

only one existing between young and older people, but it is also represented by the gap

between e.g. rural and urban populations, and rich and poor social groups [6]. Furthermore,

the presence of disabilities may exacerbate the digital divide [87]. Especially in rural and

socially deprived areas, with low (or no) availability of healthcare services, eHealth tools can

lead to better Equity in accessing healthcare, e.g. by enabling remote consultations, treatment

and rehabilitation [34].

Inequity in access to health and social care, as well as access to and use of eHealth solutions,

are crucial aspects regarding in particular the care for people with multimorbidity [80].

Although eHealth brings the promise to reduce social health inequalities, it could increase

them, if the designers do not keep in consideration that an eHealth application could be effec-

tive for one group, and with negative consequences for another one, based on physical, cogni-

tive, or cultural differences. In particular, eHealth tools could increase social disadvantages for

older people or those with low income. These aspects need to be addressed in order to reach a

universal access to eHealth [88]. Moreover, how different eHealth technologies are accessed

and used, and can “reduce or (re)produce” social inequalities in health, depend on the context

in which institutional and political context they work [89].

The low impact of eHealth technologies on equity for healthcare access is also due to the

fact that users are often only marginally involved in the development [59]. This lacking

patient-centeredness in turns could produce usability obstacles [90], or high attrition rates,

that is the proportion of consumers who stop using technologies which are not perceived as

useful or easy-to-use [91]. Conversely, the development of “need-driven” eHealth tools proto-

type, by involving especially older people end users, could be more effective [92]. Several study

findings in particular suggest that patient portals should allow easy visually engaging and user-

friendly navigation, to be realized by an early-stage involvement of patients in design and

development of eHealth solutions [93–95].

Encouragement, Enabling, Extending

Encouragement of a new interaction between patient and health staff, Enabling communication

in healthcare context, and Extending the scope of healthcare in a geographical and conceptual

meaning, these all represent factors that could positively impact integration and management

of care. In particular, integration and management of care were referred/perceived as key

potential benefits of eHealth by program managers interviewed in the ICARE4EU study,

eHealth for people with multimorbidity

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especially for older people. On the other side, an appropriate management (and coordination)

of the eHealth tools (e.g. objectives, organisation), respective responsibilities of actors and allo-

cated resources is needed, given that it impacts the outcomes from eHealth technologies them-

selves [59].

Encouragement “towards a true partnership, where decisions are made in a shared manner”

[6] could in particular facilitate a “multidimensional approach towards professional change

management” [26]. Such an approach engages all involved actors including patients, and

regards changing of organisation, work processes and behaviours, which all represent difficult

goals to be achieved when improving health and social care service delivery. eHealth applica-

tions can contribute to renew the patient-professional relationship, with impact on the

empowerment of patient [27] at the micro level of care, i.e. regarding strictly the relation

patient-physician, and at the meso/macro level of care, i.e. on institutional and policy levels

[96]. A recent study [97] put in evidence that eHealth might enhance interactions with patients

and their effective care, and that new technologies may be of help in managing changing

demands of patients themselves. eHealth indeed develops home-based solutions which are

integrated within the national/regional healthcare systems, with improvement of functionali-

ties such as information, education, and communication of/with patient [74, 98]. The commu-

nication and exchange of electronic information between patients and providers should

especially regards the relationship with the GP and primary care providers, who are the key

actors caring for older person with multimorbidity [3]. In particular, GP is perceived by family

carers as a real “support service” in terms of information, counselling and emotional/psycho-

logical support [99]. According to data from the Survey of Health, Ageing and Retirement in

Europe (SHARE), regarding people aged 50 years and over in 16 European Countries in 2011–

2012, multimorbidity is linked to increased primary care utilization, and particularly to

increased number of visits by GP [100]. GPs have a crucial role regarding health literacy of

older patients [101], given their long-standing confidence and familiarity with them [102].

However, some authors [103] found that GPs used eHealth tools more frequently for their

own needs and less frequently for their patients.

Beside a new relation patient-physician, Enabling “information exchange and communica-

tion in a standardized way between health care establishments” [6] represents a further aim for

eHealth tools. Their adoption within the healthcare system implies a full and standardized

coordination of the communications among healthcare professionals, patients and informal

caregivers, especially when disease management regards multimorbidity, with several profes-

sionals involved [59, 104]. Currently eHealth is not yet a major component in most healthcare

systems, and standardization should be increased in both national and European contexts in

order to achieve its potential [34]. Including all relevant stakeholders in such a process could

add success to the final desired outcomes [30].

The role of technology in facilitating the integration, communication and sharing of infor-

mation among providers/professionals and between professionals/providers and patients,

“wherever they are based”, seems a crucial/strategic issue [105]. Extending the aim of health-

care “in both a geographical sense as well as in a conceptual sense” means in particular that

eHealth services, ranging from “simple advice to more complex interventions” can be obtained

from online global providers [6]. Via eHealth patients can reach various providers which are

located in different countries, in order to have for instance a first or second opinion on a spe-

cific treatment, or to use a specific online healthcare service, especially useful for those living

in remote and “conventionally” inaccessible areas [106]. Telehealth in particular can overcome

social and geographic inequalities, by allowing more people to receive health care [50]. The

possibility to connect suppliers and users in the whole Europe, allowed by communication

technologies through an integrated/coordinated involvement of professionals and

eHealth for people with multimorbidity

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stakeholders, seems essential in the cross-border healthcare services, thus improving the conti-

nuity and quality of care across Europe [107].

The potential of eHealth in terms of Encouragement of a new interaction patient-health pro-

fessionals, Enabling standardized communications, and Extending the scope of healthcare, as

described above, can face obstacles as those indicated also by ICARE4EU results, e.g. the cul-

tural resistance to adopt eHealth (both by patients and providers), that in turn could affect the

possibility to “encourage” the access to healthcare services enabled by eHealth technologies. It

is to keep in consideration that a good patient-physician relationship could be hard to reach,

given that for the patient it is difficult to trust online rather than face-to-face, and moreover

sometimes with unknown and different professionals, with whom the patient has not yet a

relationship. This in turn could lead to fragmented and inappropriate healthcare [50]. In this

respect, a “careful management” of patient-physician relationship could conversely encourage

the adoption of health technology, to support especially people with chronic disease [108].

Video consultations in particular seem to work better than face-to-face consultations when

health professionals and patients already know and trust each other [49]. Some authors in a

recent study [109] highlighted however that the quality of patient-provider communication

did not differ significantly between web-based and face-to-face consultations, and both seem

to offer the same satisfaction/interaction level.

For Enabling communication in a standardized form between providers/professionals, and

for Extending the scope of healthcare in a geographical and conceptual meaning, a good

eHealth governance also seems particularly crucial, e.g. the provision of adequate funding and

incentives, as well as technical, institutional/organisational structures [110]. Especially tele-

health services has potential to reach successful outcomes, but its applicability could remain

low due to technology and infrastructure required, and related costs [111]. These barriers in

turn could affect the possibility of innovation, as development of new eHealth tools. In a gen-

eral sense, willingness to innovate by providers and stakeholders should be fostered with

opportunities raising dialogue, exchange of standardized information and awareness on poten-

tial benefits of eHealth [26]. The involvement of providers and stakeholders in productive dis-

cussions and decision-making process about possible healthcare innovation could facilitate the

acceptance of new ICT-based tools [112]. Moreover, an effective innovation could be achieved

only by supporting interoperability and compatibility of technology between various and dif-

ferent healthcare ICT applications and systems [113]. This represents a challenge to be care-

fully managed [114], both within and between European countries, in order to implement a

homogenous/harmonized framework for the exchange of health information used in cross-

border services [30, 107]. In particular, EHRs, which are based on data reported by healthcare

providers, are often stored in a fragmented way in different structures. These aspects impact

the interoperability and the related data exchange between health professionals and providers

[115]. Both technical and semantic interoperability of different eHealth applications should

then be guaranteed, in order to obtain benefits from integrated healthcare information systems

[26].

Furthermore, Enabling a standardized communication faces in particular the barrier of pri-

vacy and security issues. Collaboration between care professionals, when supported by adop-

tion of eHealth options, remains difficult in practice, partly due to a lacking or not clear

legislation for the protection of privacy and security [80], as already stated above regarding

particularly Ethics aspects of eHealth. When healthcare organizations substitute traditional

care with “care at distance”, it is very important that secure systems are used [116]. To assure

private and secure communication could encourage patients to adopt a new online relation

with health professionals, in particular with regard to telehealth use. In this case, several types

eHealth for people with multimorbidity

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of patient safety risks emerged, mainly related to various tasks and practices and to the per-

sonal characteristics and capabilities of users/informal caregivers [73].

Limitations

The ICARE4EU study presents some limitations [31–33]. First, our overview of integrated

care programs for multimorbidity in European countries reported the impact of eHealth appli-

cations as perceived by country-experts and program managers, without including the impact

of eHealth on quality of life and quality of care as perceived by patients and their caregivers, or

the impact on integration of care as perceived by care providers. Second, the survey was

dependent on the personal expertise of country-experts and program managers participating

in the survey. In some cases, they might not have had complete knowledge of all multimorbid-

ity care approaches and programs operating in their countries. Third, eHealth aspects that

were considered relevant for multimorbidity care were mapped, but comprehensiveness of

data collection on the phenomenon cannot be assured. Moreover, our analysis has some limi-

tations: the “10 e’s” in eHealth by Gunther Eysenbach are not specific for technologies adopted

within integrated care programs for multimorbidity, whereas it was conversely the aim of our

study, and moreover they were identified in 2001; in many cases further benefits/barriers/

other results could be associated to each of these essential “e’s”, but it was decided to highlight

those most supported by ICARE4EU findings and previous/current literature.

Despite these limitations, regarding both the ICARE4EU study and the analysis that was

carried out for the purpose of this paper, the relatively high number of eHealth initiatives

which were mapped in the context of multimorbidity care, contributed to raise knowledge in

the field, and confirmed the relevance of the “e’s” in eHealth focused by Eysenbach more than

15 years ago. These seem crucial factors still valid and applicable in the current context of

eHealth deployment for multimorbidity care in Europe.

Conclusions

The increasing incidence of chronic diseases, and the issue of how to appropriately meet the

complex care needs of people, especially those with multimorbidity and mainly elderly, calls

into the question the role of eHealth options within healthcare services. In this respect, some

important aspects impacting care integration and management, as well as cost-efficiency and

quality of care and life, can be identified on the basis of both ICARE4EU findings and the “10

e’s” in eHealth by Gunther Eysenbach [6]. These aspects could be considered as potential

objectives of new policies which could support the development and use of eHealth technolo-

gies within integrated care across Europe [34].

First of all, for a positive adoption of eHealth tools the following aspects seem crucial: devel-

oping adequate/clear legal frameworks (e.g. on access to EHRs by patients), with attention to

ethics aspects such as privacy/security issues; to provide innovative and sustainable funding

systems, incentives and reimbursement mechanisms for large scale implementation of

eHealth; to have adequate technical, institutional and organisational infrastructures facilitating

communications between care providers; to assure interoperability and compatibility of tech-

nologies between different ICT tools/systems, and standardization of processes. A whole “digi-

tal framework”, potentially at a national/regional level, seems thus needed, in order to

understand the complex interactions between the different eHealth tools [58].

Moreover, a cultural acceptance “to change” should be based on the provision of education

and training to patients, family caregivers and health professionals on digital health literacy,

which contribute in a complementary way to achieve patient-centred care, empowerment and

self-management. In this respect, it seems important to ensure equitable access to eHealth

eHealth for people with multimorbidity

PLOS ONE | https://doi.org/10.1371/journal.pone.0207292 November 14, 2018 17 / 26

applications to more vulnerable subgroups of the population with scarce digital skills, with par-

ticular attention to older persons, who could greatly benefit from eHealth adoption.

However, to have successful outcomes of eHealth, thus enhancing the quality of care and

life, it seems crucial to carry out large-scale and longitudinal research studies producing robust

evidence. Internal and external evaluation are required for verifying the impact of eHealth

tools on patients and caregivers, on cost-effectiveness and efficiency of eHealth applications,

and on usability and appropriateness of such new technologies. Innovation and development

of new eHealth tools could further be based on evidence. In particular, Eysenbach stated that,

in addition to the essential “10 e’s” in eHealth, eHealths itself “should definitely exist!”. This

could mean that it is fundamental to create eHealth tools, to innovate and provide new tech-

nologies, e.g. specifically developed for a particular care program, when possible, instead of

using or adapting existing tools.

A holistic and inclusive approach seems needed to address successfully issues such as tech-

nology, management and finance, in addition to human/contextual factors and stakeholders’

involvement, when planning, implementing, and evaluating eHealth applications [59]. Such

an approach could really extend the scope of healthcare in a geographical and conceptual

sense, and promote new opportunities for collaboration and investments in relevant eHealth

technologies. In particular, in order to increase the possibility of success, future research on

eHealth interventions should be directed towards the impact in the quality of care, with atten-

tion to management and patient-centered care [117]. The recent Communication from the

European Commission [118] highlights particularly personalized medicine as a priority of

eHealth, besides citizen empowerment and secure/safe access to electronic data. Researchers,

practitioners and policy makers should finally aim to work together for achieving the final

promise of eHealth tools for patients and most disadvantaged social groups.

Supporting information

S1 Table. Number of programs using at least one eHealth tool by main general aspects.

(DOCX)

S2 Table. Number of programs using at least one eHealth tool by categories.

(DOCX)

S3 Table. Number of programs using at least one eHealth tool by some specific aspects.

(DOCX)

S4 Table. Programs using at least one eHealth tool and focusing older people 65+. Benefits

and barriers (number of agree).

(DOCX)

S1 Text. Survey questions used in the study.

(DOCX)

S1 Dataset. Minimal dataset used for the analyses.

(ZIP)

Acknowledgments

The authors wish to thank the ICARE4EU partners for contributing their expertise: Mieke Rij-

ken, Iris van der Heide, Sanne Snoeijs, Francois G. Schellevis (Netherlands Institute for Health

Services Research, NIVEL, Utrecht, The Netherlands, coordinator centre); Ewout van Ginne-

ken, Verena Struckmann, Reinhard Busse (Technische Universitat Berlin, TUB, Berlin,

eHealth for people with multimorbidity

PLOS ONE | https://doi.org/10.1371/journal.pone.0207292 November 14, 2018 18 / 26

Germany); Anneli Hujala, Sari Rissanen, Helena Taskinen (University of Eastern Finland,

UEF, Kuopio, Finland); Aileen Clarke, Mariana Dyakova (University of Warwick, Warwick,

UK); Marja Pijl (Eurocarers, Belgium); and Alice Sinigaglia, Ilenia Gheno, Maude Luherne

(AGE Platform Europe, Belgium). The European Observatory on Health Systems and Policies

(OBS, Belgium) participated in the ICARE4EU project as a supportive institute. The authors

wish to thank in particular Mieke Rijken and Anneli Hujala for reviewing this publication.

The authors wish to thank also all the country-experts and the programs managers who con-

tributed to the ICARE4EU project. The content of this paper is the sole responsibility of the

authors; it cannot be considered to reflect the views of the European Commission or any other

body of the European Union.

Disclaimer

The authors partially reused and adapted some quantitative data presented from their own

previous publication concerning the main ICARE4EU study, with appropriate attribution [31,

Melchiorre et al., eHealth in integrated care programs for people with multimorbidity in Europe:insights from the ICARE4EU project.Health Policy. Special issue: Integrated care for people livingwith multimorbidity. 2018;122(1): 53–63].

Author Contributions

Conceptualization: Maria Gabriella Melchiorre.

Data curation: Maria Gabriella Melchiorre, Francesco Barbabella.

Formal analysis: Maria Gabriella Melchiorre, Francesco Barbabella.

Funding acquisition: Maria Gabriella Melchiorre, Giovanni Lamura.

Investigation: Maria Gabriella Melchiorre, Francesco Barbabella.

Methodology: Maria Gabriella Melchiorre, Francesco Barbabella.

Project administration: Maria Gabriella Melchiorre, Giovanni Lamura.

Resources: Maria Gabriella Melchiorre, Giovanni Lamura, Francesco Barbabella.

Software: Maria Gabriella Melchiorre, Francesco Barbabella.

Supervision: Maria Gabriella Melchiorre, Giovanni Lamura.

Validation: Maria Gabriella Melchiorre, Giovanni Lamura, Francesco Barbabella.

Visualization: Maria Gabriella Melchiorre.

Writing – original draft: Maria Gabriella Melchiorre.

Writing – review & editing: Maria Gabriella Melchiorre, Giovanni Lamura, Francesco

Barbabella.

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